Treatment for Tibial Torsion

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I have a son who is now 20 months old. He was diagnosed by our local pediatrician as having tibial torsion. It is extremely visible. We have taken him to a specialist in Syracuse, New York at the Syracuse University Medical Center. He took x-rays, and told us that the bone growth looked excellent, both at the hips and the knees, and that he wanted to see us again in six months to do more x-rays to watch the bone growth. We are concerned that there may be other opinions regarding the use of corrective devices, and don’t want this window of opportunity to slip by, as we wait six months at a time.Rodger Moran – Oneonta, New York

Dr. Greene’s Answer:

Many parents share the concern that their children’s feet don’t line up straight. The most common cause of in-toeing in toddlers is internal tibial torsion (the large bone in the calf is rotated inward). Tibial torsion is usually a result of normal positioning of the baby in the tight space of the uterus. Some degree of tibial torsion is normal throughout infancy.

When a child begins to pull to stand, and then to walk independently, tibial torsion usually begins to correct spontaneously. In most children this process is complete within 6 to 12 months after independent walking. Spontaneous correction can continue to occur for years after this. By mid-childhood, a small percentage of children will continue to have significant tibial torsion.

For many years, the standard treatment for internal tibial torsion was the Denis-Browne splint, an 8- to 12- inch bar, worn at night, with the feet facing out at about 45 degrees. This device seemed to work quite well — almost all of the children who wore one experienced slow, steady improvement and then disappearance of their severe tibial torsion. The device worked so well that it was taken on faith. No controlled studies were done. They were felt to be unnecessary.

In June 1991, Heinrich and Sharps published a prospective, randomized, controlled analysis of the Denis-Browne splint (Orthopedics). The splint did work very well. But doing nothing at all worked equally well. Almost all children corrected spontaneously with or without the splint.

Since 1991, many other splints have been designed to “treat” this condition, but no non-surgical treatment has been shown to be any more effective than doing nothing at all for young children with uncomplicated internal tibial torsion (Journal of the American Academy of Orthopaedic Surgeons, 11(5) 2003). Still, old habits die hard, and it is not difficult to find textbooks and doctors who recommend the use of some type of nighttime device. My favorite of these is the recommendation that the child sleep on the back, to let gravity pull the feet outward (face-down children usually point the toes in). This recommendation is inexpensive, non-invasive, and makes some intuitive sense. As far as I know, it has yet to be studied. Some people sew bulk to the front of the pajamas to make it uncomfortable to sleep on the tummy, but I wouldn’t go to this much trouble.

Indications to see a specialist sooner than later include worsening rotation, frequent tripping, pain with walking or difficulty wearing shoes. Otherwise, internal tibial torsion corrects in a majority of children by about age 4 without any need for intervention.

In a minority of children, the feet are still turned inward by more than 15 degrees at age five, spontaneous correction is unlikely. For these children, surgical derotation is an effective treatment. Typically, the best window for this is between 7 or 8 and 10 years of age.

Interestingly, a study published in the summer of 1996 in the Journal of Pediatric Orthopaedics contained good news for those whose internal tibial torsion doesn’t completely correct, but isn’t severe enough to indicate surgery. The fastest runners tend to fall in this category. Top sprinters, in particular, are significantly more likely to be in-toed than the general population.

Note: External tibial torsion is out-toeing caused by outward rotation of the large calf bone. It results from a normal variant position of the baby in the uterus. Like internal tibial torsion, external tibial torsion does not begin to correct until the baby begins to walk. In most cases correction is complete by age 2 or 3.

Dr. Greene is the founder of DrGreene.com (cited by the AMA as “the pioneer physician Web site”), a practicing pediatrician, father of four, & author of Raising Baby Green & Feeding Baby Green. He appears frequently in the media including such venues as the The New York Times, the TODAY Show, Good Morning America, & the Dr. Oz Show.

One Comment

Kristal Wheaton

Hi Dr. Green,

My son was diagnosed with External Tibial Torsion in 6/2011 and surgery was performed on legs 8/2011 to correct the disorder. The initial recovery period spanned a period of nearly 12 months. I believe it was 7/2012 when he was able to ride his bike again, however, it took another 12 months before he was able to ride for any extended period of time. The same is true in regards to his walking endurance. As such, I started him in swim 10/2012, which he has continuously participated in over the last 2 years. Recently we started seeing an Occupational Therapist to begin working on strengthening and stretching his lower leg muscles. According to OT, now is an ideal time to begin more intensive activities which will build and strengthen his muscles.

Here is why I am contacting you:

My son’s father recently initiated contact with my son and has petitioned the court for visitation. My son spent 3 weeks last July with his father in which he did very little physical exercise. When he returned we of course began swim lessons again, however, my son was somewhat discouraged by the fact that his endurance was less than before he left for his visit with his father.

This summer he is supposed to spend 4 weeks with his dad. The problem is that his father refuses to enroll in swim classes, or participate in OT sessions. As such, I am reaching out to experts in the field who can provide information regarding the recommended treatments for this condition. I understand that you cannot provide a recommendation for my son specifically, but I am hoping that you can provide your opinion on the importance of maintaining regular exercise for children with this condition, and also the impact that extended periods of sedentary living (e.g. 4 to 6 weeks) will have on a child’s overall progress.